Holly Springs School for Early Education Registration

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Child

Please enter the child's full name (example: use Joseph not Joe)

First name *

Middle names

Last name *

Preferred name

Gender *

Male

Female

Date of birth *

Language spoken at home *

Street address *

Address line 2

City *

State *

Zip Code *

About your child

Please give any information concerning your child which will be helpful in their experience in a group setting such as play, eating and sleeping habits, special likes or dislikes. If none enter none.

About your child *

Program

Please select the school year and the meals your child will receive.

School year

Meals

Breakfast

Lunch

PM snack

Parent or legal guardian

Title *

First name *

Last name *

Relationship to child *

Street address *

Address line 2

City *

State *

Zip Code *

Enter telephone numbers as 10 digits with no other characters

Include mobile and work telephone if applicable

Primary telephone *

Type *

Email address *

Second telephone

Type

Third telephone

Type

Employer

Employer address

Second parent or legal guardian

Title

First name

Last name

Relationship to child

Street address

Address line 2

City

State

Zip Code

Enter telephone numbers as 10 digits with no other characters

Include mobile and work telephone if applicable

Primary telephone

Type

Email address

Second telephone

Type

Third telephone

Type

Employer

Employer address

Authorizations

Image authorization

I authorize my child to be photographed or videoed for group activities. I understand that my child's photograph or video may also be posted on the schools website or facebook page. My child's name or personal information will NEVER be revealed in these public outlets without prior consent.

Image authorization *

Yes

No

Sunscreen authorization

I authorize the staff at Holly Springs School for Early Education to apply Rocky Mountain Sunscreen SPF 30/35 to my child, as specified below, when he or she will be playing outside, especially during the months of April through September and between the hours of 1:00 am and 4:00 pm. I further understand that sunscreen may be applied to exposed skin, including but not limited to tops of ears, nose, bare shoulders, arms, and legs. Be sure to apply sunscreen to your child in the morning at home.Question: Is Rocky Mountain Sunscreen Gluten Free?Answer: All of Rocky Mountain Sunscreen's formulas are 100% Gluten Free.

Sunscreen will not be applied to any child under the age of 6 months.

Sunscreen authorization *

I have consulted with my child's physician, and do not know of any allergies or allergic reactions my child may have to Rocky Mountain Sunscreen SPF 30/35

I will provide the school with alternative sunscreen, and complete the necessary forms to do so.

No. For medical reasons, do not apply sunscreen to my child under any circumstances.

Walking authorizationI authorize my child to participate in the school offsite evacuation drills throughout the school year. I understand that each drill will take place in the neighborhood area and the children will always be accompanied by a teacher.

Walking authorization *

Yes

No

How did you hear about us

Please tell us how you heard about us: e.g., sign outside, referral (please tell us who referred you), advertisement (please tell us the name of the publication)

How I heard about Holly Springs School

Release for pickup authorization

Should you be unable to pickup your child, please give the names of persons to whom your child can be released. (Persons must be 18 years or older)

Authorized pickup name

Relationship to child *

Authorized pickup name

Relationship to child *

Authorized pickup name

Relationship to child *

Authorized pickup name

Relationship to child *

Emergency contacts

If neither parent or legal guardian can be contacted list alternatives. (Persons must be 18 years or older)

Enter telephone numbers as 10 digits with no other characters

Emergency contact name *

Relationship to child

Telephone *

Telephone

Emergency contact name

Relationship to child

Telephone

Telephone

Emergency medical contacts

Physician name *

Physician telephone *

Physician address *

Dentist name

Dentist telephone

Dentist address

Hospital name

Hospital telephone

Hospital address

Medical information

Allergies

Please list your child's known allergies. If none enter none.

Allergies *

Health forms

North Carolina requires that you provide us with a Child's Medical Report and Immunization Record completed and signed by a licensed physician, his authorized agent currently approved by the N.C. Board of Medical Examiners (or a comparable board from bordering states), a certified nurse practitioner, or a public health nurse meeting DEHNR standards for EPSDT program.

Please provide the date of the most recent physical examination.

Physical examination

Medical insurance

My child is covered by the medical insurance policy listed below. I accept responsibility for all medical expenses incurred by the child care provider on behalf of my child.

Insurance carrier

Policy number

Group number

Name of policy holder

Financial agreement

I agree to the following terms of payment to Holly Springs School for Early Education.Monthly tuition is due on the 1st of each month. (Late fees begin if payment is not made by the 5th) or on the 1st and 15th for multiple children (late payments will be charged after the 5th and 15th of each month as needed for non-payment)

Only a max of 2 discounts per family unless otherwise approved by management. All discounts apply to the oldest full time sibling• 5% Educator to Educator Discount• 5% Military Discount• 5% Town of Holly Springs Employee• 10% Sibling Discount

I acknowledge that if my payment is later than the 5th of each month I will be charged a $25 late fee. My contract is in effect for the duration of time that my child is enrolled in the program. Payments not made in full by the 15th of the month may result in loss of care until the balance is paid in full. I agree that if I need to withdraw my child from this facility I will give a 30-day written notice. I understand that if I fail to give such notice I will be responsible for one month's tuition.

Tuition payment methodI will pay my tuition using one of the following methods (If I am using subsidized childcare assistance I will agree to pay my parent fee as written in the DSS agreement and by the 1st of each month.)

Tuition payment method *

Private pay

DSS voucher

Parent or legal guardian signature

I have read and received a copy of the facility's Infant/Toddler Safe Sleep Policy and the facility's director or other designated staff member has discussed the facility's Infant/Toddler Safe Sleep Policy with me.

I have read and received a copy of the facility's Discipline and Behavior Management Policy and the facility's director or other designated staff member has discussed the facility's Discipline and Behavior Management Policy with me.

I have received a copy of the centers Parent Handbook which contains the North Carolina Child Care Laws and Regulations and current payment policy.

I agree that the operator may authorize the physician of his/her choice to provide emergency care for my child in the event that neither I nor the family physician can be contacted immediately.

I certify that the information I have provided is accurate to the best of my knowledge.